[Carrie Y] Week 2-3 Learning

What an adventure so far! I'm sorry I've been a little MIA lately- I've been meaning to post every Sunday, but a small trip which led to food poisoning which led to me curled up at my apartment (or rather my friends apartment) near the bathroom with no internet. But that is getting a little ahead of myself.

The best way to describe India is that it is uncomfortable. I don't mean that in a negative way, but more in the sense that I am constantly tested and stretched and never really left to relax. I think that there are a few life lessons to keep in mind from India

• Always have a plan B. And if plan A fails, make plan C, if B fails have plan D, or in other words always be ready and analyze, adjust, and adapt and move on to another option. There always will be another route. 
• Be wait for things to happen- I've been waiting to be settled in my apartment to put certain plans into action. But as 3 weeks have gone by I've realized- that may not happen anytime soon. You shouldn't wait. You should do.
• Don't be too concerned about time- do things when the moment is right, not when you plan on them. But at the same time, keep your commitments. 

Most of these lessons stem from my living arrangements, my research, and my adventures. My living arrangement, surprising has probably been my best introduction into Indian culture. I've been living with a friend for the last three weeks- an arrangement that was only supposed to last one week but has turned into three. I've had 5 separate housing plans fall through and I am finally moving out tomorrow morning. (thus the plan A, B, C, D and at this point, E). In the process I've been disappointed by housing plans with co-workers falling through, had a realtor arrange something and then decided to start hitting on me instead of following through on the final details on housing I had 80% arranged and when I resorted to having my Indian co-workers talk to him stopped answering my phone calls.

Now I am moving in with a couple of social entrepreneurs who work on Solar powered energy for base of the pyramid- I think it will work out great and I will be able to pick their brains for my research project. In moving in, I am actually not as excited about a bed of my own as for a blank wall. I have been waiting and looking forward for these three weeks for a wall to paste post-it notes on and organize my thoughts- I've been journaling some and thinking lots, and I can't wait to map it all out.  I'll take pictures to share.

I've been living a 10-7 working life so far. I've started by immersing myself in work at Embrace and becoming part of the team. I've just started setting up lunch-meetings regularly with different parts of the Embrace team in order to fully understand every aspect of Embrace. Next Tuesday I am meeting with one woman who is the head of their base of the pyramid (BOP) education system and public health outreach and I'm working my way through the different sectors of Embrace. I was planning to start last week but a nasty case of food poisoning kept me out of commission completely for half the week and half-functioning for the other half. Just seeing how things work is giving me amazing insights into the innovation, hardships, and daily life of a working BOP social venture.

I've also been networking with local social entrepreneurs and trying to make as many connections as I can so that I can pick their brains for my research. I have many conversations and thoughts and I'm looking forward to taking it to the next level this month and visiting some of their facilities.

The one side just-fun adventure that I undertook was last weekend I went with some other interns I met to Hampi- an ancient religious site where we saw different temples for Ganesh and Hanuman (aka the elephant and monkey temples) among others. I think one of my favorites was we took as small circular boat made of tar and bamboo down a river, walked across a field, climbed to the top of a large mountain (something like 600 steps) to the monkey temple, to an amazing view overlooking the whole area where you could see other temples. The temple wasn't that exciting- some cement, white paint, and incense, but the view was amazing. Unfortunately, this trip also gave me food poisoning, but it was well worth it, and who knows- maybe this will make me stronger for the next time.

It has been an amazing experience so far and I am very thankful for the opportunity. For all its hardships and frustrations, I wouldn't change a thing. In summary of my life here, to be added to as my journey continues:

You know you are in India when:

• You fit 12 people in one rickshaw (a three- wheeled cross between a motorcycle and car)
• You wonder why you are in a traffic jam, and then realize everyone is just waiting for the herd of cows to finish crossing the road

[Eric R] Week 4

I seem to have really good weeks (last week in Mumbai!) followed by really bad weeks (this week in Bangalore), in terms of my project at least. Last week was extremely enlightening, and I managed to meet with many doctors at some very excellent hospitals. I learned a lot, and can tell that a bulk of my research material will come from my visits in Mumbai.

Going into this week, a great number of things changed for me. First, I moved to Bangalore, the Silicon Valley of India. I left Mumbai Tuesday afternoon, and arrived here on Wednesday late-morning by bus. The drive was spectacular, and I loved getting the opportunity to see the country a bit. I sat next to a gentleman (Shreeshan) who had studied civil engineering in Mumbai but was headed to Bangalore to interview for a spot at a college studying journalism (he got bored, he said). I enjoyed traveling with him, and the 18 hours felt more like 3 or 4.

Second, the monsoon season started! B’lore is much more elevated than Mumbai and also inland, so it’s cooler here to begin with. The result? It’s a mere 80 degrees here, completely overcast, and a nice breeze to keep the humidity at Ann Arbor summer levels. It rains for only about an hour here each day, usually in the late afternoon. In Mumbai I’m told it rains much more (up to 6-8 hours/day), but again, due to the elevation and proximity to the ocean, B’lore’s monsoon season is much less pronounced.

Third, my phone was put on hold. As a result of the 2008 terrorist attacks in Mumbai, it has become much more difficult for anyone to get a SIM card. Mine was working perfectly fine, until someone somewhere decided I needed additional verification, which includes a trip to the stall that I purchased my card at originally…in Pune. So, I’m working with OHUM to get my service restored ASAP.

This leads into my fourth change: unbeknownst to me, three of the four hospitals I wanted to meet with in Bangalore had been trying to contact me on my cell phone since Monday. They eventually all emailed me, a couple days later (the day I arrived in Bangalore), regretting to inform me that it would no longer be possible to accommodate my project. Their reasons were all because they were denied approval from their research boards. So, as far as Bangalore goes, my research has hit a wall. I’ll be visiting the remaining hospital on Monday (Manipal Hospital).

Next Thursday I’ll be attending my GSI’s wedding in Bangalore! I’m so proud of him for being the recipient of this year’s ChE Department‘s Excellence in Teaching Award, and can’t wait to be there for him! Two other ChEs, Carrie Yarina (another CSAS Fellow!) and Pete Wangwongwiroj, are also in Bangalore and are attending as well. We look forward to bonding in Bangalore!

Next Friday I’ll be taking the 35hr train trip to Delhi, the last stop for my research project! I’m looking forward to my hospital visits there – everyone I’ve talked to so far has said that Delhi is at the forefront of EMR adoption. While there I will take a weekend trip to the Taj to take that iconic picture! It will provide good closure for my trip, and I will be sad to leave this beautiful country. I can hardly believe that I passed the halfway mark, and know that the rest of my time will fly by. I plan to make the most of every moment and learn everything I can.

Until next week.

-ericr

[Eric R] Week 3

It’s time for my next post! This past week has been inspiring for me. Overall, I was very productive; I managed to make new friends, see some sights, and have many well-developed conversations with very smart people.

I ended my time in Pune with a round of laundry. Although Malik offered to take care of it himself in the communal washing machine behind the guesthouse, he also (politely) suggested I take my laundry to “My Dhobi,” a business that does your washing for you. I elected for that option, and had a lovely conversation with the manager who has traveled extensively in the southwest US, and has a niece in Auburn Hills, MI.

I had my first experience with the long-distance trains – I managed the four-hour trip from Pune to Mumbai (Dadar Station) by myself. I almost missed it; I literally hopped aboard the first car I saw, and we started chugging along (note to self: remember to print your ticket beforehand!). Luckily, I jumped onto the right one! At Dadar, I took a taxi to my hotel in Khar West, about a 10min ride. The taxi driver promised me a good deal, and tried to charge ₨2000 when his meter said ₨57. He pulled out a fare conversion card “given to him by the government,” that although looked plausible, I knew was a forgery based on the prices. I was astounded when a local started to back him up, and so I called Ketaki to make sure I wasn’t just being ignorant. In fact, the charge was ₨57. Fellow SiSA students… be careful!

I visited two hospitals this week, but had multiple interviews at each, over four days. At the first, Tata Memorial Hospital in Parel, I met with five physicians. Each chose to focus on slightly different aspects of EMR systems. I’m finding that a good first question to ask is, “What do you define as an EMR system,” followed by, “What is the difference between that, and an HIS system?” A high percentage of all hospitals here have a hospital information system (HIS) that might include modules such as “Admissions, Discharge, and Transfers,” “Bed Occupancy,” “Billing,” or “Patient Registration.” Many of the physicians, when asked if they use an EMR system, they say yes, but really are referring to their hospital’s HIS system. The key difference, in my opinion, is that an EMR system needs to provide support for clinicians when making important decisions regarding patient care. Such provisions could include patient allergy alerts, diagnosis information, prior medical histories, lab results, and all medical images. Of these features, none of the hospitals I’ve visited so far have implemented all of them. Most have implemented a module for viewing images (MRIs, CTs, etc.) and some have implemented a module for viewing lab results. But of course, the modules are all separate, and have unique login information for each.

The second hospital I visited was Fortis, Mulund, where I interviewed another five physicians, four of which were during their outpatient clinic periods. This provided a unique opportunity for me to understand the different settings in which an EMR system could be used. The number one challenge these physicians emphasized was patient volumes. There are simply too many patients to be seen each day to spend time wrestling with their computers while they’re at it. And frankly, I don’t blame them. If there is one thing I’ve seen most during my time here, it’s people. I’ve ridden the trains a few times in the last couple days, but always during off-hours. The trains and platforms have been crowded, but I’ve managed to always make it on and off the trains alright. Today on my trip to Fortis (about a 1.5hr journey), I left Khar at 9a, just as peak travel times were beginning. It was madness. I felt like a sheep being herded through a tunnel squished against a million other sheep. The transfer at Dadar was equally as crazy; there were easily 5,000 people on the station platforms at any given time. I loved having the opportunity to fit as a local, and even had some people ask me, "agle station kya hai?" (what is the next station?) To which I was able to proudly offer, "Bandra," "Khar Road," and "Nahur."

I’ve been told there is not a lack of doctors here, and I’m inclined to believe that after hearing so many of them graduate and continue into hospital administration, business, and pharmacy. From what doctors have told me, what India lacks is healthcare facilities. There simply aren’t enough hospitals to take care of every person with the same level of attention as in the US. When time is of the essence, and an “expensive” hospital consult is ₨500 ($9), doctors simply don’t care to put the effort into learning a new system and dealing with the training period required for an EMR system to stick. Not to mention the grossly inadequate amount of infrastructure – imagine having to run from the patient’s bedside to the single nursing station in the ward to check a patient’s chart one more time. Then there’s the slow Internet connection, the forgotten passwords, and my favorite, the software runtime errors.

At some point during all of my interviews, the physician says something along the lines of, “You know, all we need is a visionary – someone to come in and push for EMRs. Someone just needs to take our paper away!” If you’re reading this and feeling inspired, let me know, and I will put you in touch with the right people!


-ericr

At the Beginning

My name is Carrie Yarina, and I am a 3^rd year chemical engineering student at the University of Michigan. The reason I chose engineering as my major is because I see it as an opportunity to make substantial, tangible changes in the world for the better.

Freshman year I started my journey toward creating a non-profit that provides affordable, sustainable diagnostic equipment to people in rural India. I believe that everyone, no matter where they are born has a right to local access to healthcare; however in rural India is not a right- it is a luxury. With a tool that my team and I designed freshman year we plan to take diagnostic capability out of the clinic and directly to the people who need it the most: in rural villages where there is no electricity and the nearest clinic is over 15 km away. I am currently the CEO and co-founder of this non-profit, called CentriCycle. (see more at centricycle.com)

This project is what brought me to the Summer in South Asia Fellowship. The further I go and the more I learn while working on CentriCycle, the more I realize I do not know, and the more I want to learn. I was recommended this fellowship by a friend who had gone through this experience, and I saw it as a means to fill in some of my knowledge gaps.

The research project I decided to work in is on how companies design and market to the base of the pyramid (people who live on less than $2/day).  This is an emerging sphere in the non-profit/social venture world. All over the world, people are trying to develop sustainable businesses or non-profits that can reach this market and make enough money to be self-sustainable, with mixed results. The area that I am most interested in, which is the medical sphere, is even more complicated due to the regulatory and high up-front costs and time that must be invested. It’s an exciting time to be in this market, but also a scary one.

That is why I decided to volunteer at Embrace this summer. They are an organization that makes low-cost infant warmers designed to save the lives of low birth-weight babies by keeping them warm so that they can use their energy to develop and stay alive, rather than just staying warm. They are an interesting company, because they recently created a branch that is for-profit, and that is where I am volunteering at. I’m working on and being involved in every step of the design process, from prototyping to clinical trials, and hopefully, the the launch of this product. What better way to learn about the process, than to learn from the company that has become the poster child of medical device design for the base of the pyramid? Now, I’m not saying they have it figured out- they also have a long way to go, but hopefully, by learning from one of the companies that is doing this the best, I will be better equipped to take the leap with CentriCycle and launch our own successful social venture. 

 

 I'm at the beginning of my adventure and I'm excited to see how it will turn out! I just finished my first week in India I've been staying with a friend of a friend until I get my apartment finalized. It's already been a great experience and a bit of a culture shock (but in a good way).  Bangalore is hectic and crazy and frantic all of the time. I'll let you know more once I get everything settled in my new apartment!

[Eric R.] Week 2

I had an extremely productive end to my week! It began quite slowly – I finished making calls to all of the hospitals that I hope to visit in the next five weeks. Hopefully I spoke to all the right people! It has been extremely difficult trying to navigate the various levels of bureaucracy of the Indian hospital system…

Yesterday, I had my first interview scheduled, at Sahyadri Specialty Hospital. I asked the two other interns in my office to come with me on my first visit, to ensure that I didn’t drown before learning to swim! They ended up being very helpful. I walked into the very busy hospital and approached the information counter. I let them know that I had an appointment with the Medical Director, who happens to be the head of neurosurgery as well. Turned out he was in surgery, and was unable to spend time with me. The woman at the information counter pointed us upstairs to the HR department, who told me that first, I needed approval from the Corporate Office, located five minutes down the road. Well. We took the trip to the CO, and were waved into the HR Manager’s office, a man named Mr. Moses. During introductions, he let us know that he spent some time in North Dakota during college as an exchange student, and after mentioning that I attend UofM, he said he was offered an American football scholarship there, and turned it down! I was shocked. Mr. Moses was very helpful, and after getting a better understanding of what my project was all about, informed me that Sahyadri doesn’t use an EMR system. Exasperated, we left the CO in search of other hospitals in Pune.

Yogendra, one of the other interns at OHUM, is also a doctor, and suggested we visit a few hospitals to see if they would grant me an interview on the spot. We were 0-for-2 when we rode into Sancheti Hospital, a more community-oriented hospital specializing in orthopedics. We went to the Administrative Offices, and were waved right into the Administrative Director’s office. Dr. Vaidya was gracious enough to let me have an interview with him, and I learned an immense amount in our short time together.

I’ve observed many things this week; most importantly, people here, although extremely gracious and pleasant, are extremely indirect and not proactive. 95% of my emails are ignored, and it takes going through six different people on the phone to get where I need to be. After reaching the correct person, they result in the classic, “Why don’t you email me?” There are N-number of times (to borrow a phrase I’ve heard often here) that someone along my journey could have said, “Oh, don’t bother with Sahyadri – they don’t have an EMR system,” or “Try Sancheti Hospital, I know they are generally very helpful.”

This observation directly affects my current opinion of EMR systems in India – I believe the country as a whole is simply unprepared and unwilling to adopt such systems. Until the government decides to take steps to enforce EMR adoption (unrealistic), only the biggest-and-richest hospitals are going to consider moving in that direction.  I’m excited to visit a Max Hospital – they are one of the largest hospital chains in India, if not the largest, and they have implemented an EMR system across all of their locations. I’m scheduled to meet with them at the end of my trip, in Delhi.

I am heading to Mumbai on Sunday to visit four hospitals. This will be the true test of my preparation, and I look forward to visiting larger hospitals there. And who knows, maybe one of them will be a full-fledged, model-EMR hospital? What’s that? You have another question for me? How ‘bout you send me an email, and I’ll get back to you…

-ericr

[Eric R.] Week 1

To make up for  my lost post, I will begin by introducing myself.

My name is Eric Raynal, and I am a senior studying Chemical Engineering. I will be graduating in December 2012, and plan to attend medical school in 2013. I'm in the process of finishing up my primary application, and will submit it before I return to the US on July 3rd. I'm from Petoskey, MI, but since matriculating, my parents moved to Ann Arbor! I am fortunate to have them close by, and try to visit once a week.

Just a touch on what I've been doing in my free time before discussing my project. Between my friends Grace and Sahil, and Wikipedia, I have learned quite a bit about the rules of cricket. The IPL playoffs are just about to start, and I can say with pride that I have a basic understanding of what's going on. In the evenings, I have been watching Mollywood/Bollywood/Tollywood/Kollywood/Lollywood/Sandalwood films on TV. Most are from the 60's/70's and none have subtitles, so it's been interesting trying to catch the differences in languages!

I cannot thank the generous donor enough for creating such a wonderful opportunity for students to travel to India. When I heard about the fellowship, I immediately began coming up with different topics and project ideas. I sought to create a project that used my engineering background to tackle a medically-related issue. What I came up with is a research project focused on electronic medical record systems in India. I am here to discover some of the challenges that Indian clinicians face using these systems. Do they successfully address the needs of the hospital? Is there sufficient ongoing IT support from EMR software companies? Do clinicians receive adequate training on their system? Are the systems even being used after their installation?

To determine the answers to these questions, I developed a set of questions to ask doctors during one-on-one interviews with them. I will be visiting hospitals in Pune, Mumbai, Delhi, and Bangalore. To get a better sense of the current environment and attitude towards EMR systems in India, I have begun my trip by spending some time with OHUM Healthcare Solutions, an EMR software provider in India. I have spent the last week playing in a training environment of their EMR software that has been slightly modified from the US Veterans Health Administrations's EMR software, VistA.

I've learned that things move slowly here! Not only the pace of life, but productivity as well. I have been towing the line between polite and pushy to accomplish the goals of my project. The two other interns that started with OHUM the same day as I did still have not been assigned a project. My primary contact at OHUM was suddenly and unexpectedly called back to his home in Chicago, and will not be returning to India for some months. I have been working with another chief staff member, Niteen, but he has been absent from the office twice this week. I have critiqued and finalized the outline I will use during interviews, and am prepared to begin as soon as possible.

Unfortunately in India, that is in all probability next Monday!

-eric
ericrayn@umich.edu

[Eric R.] Initial Post

So, apparently my previous post is lost. I apologize! It was mostly about packing, and my running around to prepare for departure. I also gave a quick introduction to my project, and what I'll be working on while here. I will be sure to write about my project in the future.

This has certainly been an adventure, so far! I landed in Mumbai at 11.15p last night, and made it through customs and immigration very quickly. I was supposed to be looking for my driver, Santosh, who had a placard with my name on it. I exited the airport into a square surrounded by people, all holding placards! I had been warned of the smell – that I’d want to walk back inside and fly home. I can officially say, it’s not worth all the hype. Mumbai smells…humid, and a touch musty. But not bad.

I ended up using my phone briefly to call Santosh, and found him standing shyly in the corner with my placard: “Ayrik Reylan.” I suppose that’s close enough. I went with him to his car, and began the drive to Pune. Let me tell you, easier said than done. At first, there was only one tiny road. It wound through the slums of Mumbai, and had potholes and construction everywhere. Bikes and auto-rickshaws were weaving in and out of traffic, and sometimes the cars would come into the wrong lane to avoid a particularly large pothole (don’t forget they drive on the left, with the steering wheel on the right!). After leaving the island that Mumbai is on, we began to travel up into the mountains. Despite being about 1am, traffic was gridlocked. Going up into the mountains was slow going; cars were in the minority, and large trucks carrying carefully-balanced loads blocked most of the road. Driving on the shoulders was commonplace. My favorite sign I saw: “over-speeding causes accidents. Slow down.” Not speeding, just over-speeding. I heard (and sang along to) a medley from Kal Ho Naa Ho on the drive, and a few others I recognized from the films I’ve seen.

I rolled into Pune at 3.40a, and was greeted by Malik, who has become my guide for the time being. He showed me my room, and I was pleasantly surprised when he turned on the A.C. before leaving me for the night. I am fortunate enough to enjoy sleeping on a firm mattress; I think my bed is more like a cushion on a piece of plywood!

I slept very well, but briefly. I woke up at 8.30a when Malik walked in and asked if I’d like some tea. I said yes, of course, and came downstairs for some tea and crackers. He likes the word “going,” and uses it synonymously with “coming.” It made for some interesting conversation this morning, and we ended up walking a couple blocks around the guesthouse due to a misunderstanding (on my part, clearly!).

Malik asked me this morning if I was married; after clarifying to ensure I understood him, I quickly told him no! He laughed a bit, and said at 25/26/27 he will get married (he’s 20, I think). I told him I was only 21, and he told me I should start looking! We talked a little about our families, and bonded a bit. I hope we become friends!

Mr. Kumar, my contact at OHUM, is in Delhi today, and will be returning Saturday. However, I visited the OHUM office for an orientation this afternoon. There are two other interns starting with me; they are Masters in Health Administration (MHA) students (Ketaki and Yogindra). Yogindra is a doctor already, but is interested in managing a hospital. Apparently, about half of all Indian medical students do not practice medicine after graduation, but continue on to receive their MHA's, MBA's, etc. The three of us met with a number of employees at OHUM, and learned about their mission statement and their main piece of software, VistA. My task for the rest of the afternoon: read the 144-page user's manual to have more background information when I go to meet with doctors starting next week...wooo!!!!

-eric